Does anyone have a clue about the significant differences in mortality rates in COVID infected people between Germany and other countries (Spain, Italy, France…)?
Germany is a densely populated country (86 000 000 inhabitants in just 360 000 square kilometers), with several very populated cities. Nevertheless it is not being hit by COVID as hard as other countries. Are German doctors treating patients in a different way?
I know that probably the explanation is complex:
1. Germans as Oriental people, may be more disciplined than Mediterranean people, and that could justify a slower spread of infection. There may be genetic differences.
2. Probably there are differences in the definition of infected cases and COVID mortality. We know that they have made more PCR tests so their definition of case is wider, and that could explain lower relative figures (number of deaths per each infected people). But absolute figures are also lower. On the March 22th they had only registered 68 COVID deaths.
3. The number of ICU beds could explain some differences (with 28,000 ICU beds, Germany is the first in the ranking of ICU beds (6 ICU beds per 1,000 inhabitants), while Italy has 2.6 ICU per 1,000 inhabitants and Spain only 2,4). (https://www.euronews.com/2020/03/19/covid-19-how-many-intensive-care-beds-do-member-states-have)
4. They could be in an earlier phase of the epidemic. So the figures could worsen in the next days.
In any case they seem to have less severe cases. There may be biological differences between different populations. Still the differences in the absolute figures are really striking.
I would like to open a debate about the standard treatment in Germany vs the standard treatment of COVID infection in other countries.
Are they doing something different?
Is there something we should learn from them?
Best regards from sad Spain.
Julio.
Article Checklist Proformas to Guide and Document the Assessment of ...
I have no experience with the management of patients in Germany. However, the very high mortality of patients in Italy is at least partly because they had very little time to prepare for this pandemic. Many healthcare workers were infected before adequate PPE was available. This depleted the capacity to deliver healthcare and specifically intensive care. So, as the COVID 19 pandemic progresses we will need to upskill colleagues to facilitate the assessment and treatment of critically ill patients with and without COVID 19.
This may be achieved by face-to-face education sessions. However this is very labour intensive and may result in spread of COVID 19 amongst healthcare professionals.
An alternative approach would be to use standardised checklist proformas for the assessment of critically ill patients (see link below).
Article Checklist Proformas to Guide and Document the Assessment of ...
The use of checklist proformas can facilitate the management of critically ill patients by staff who do not routinely work in intensive therapy units. This could improve outcomes in this high risk cohort of patients and improve the confidence of staff redeployed to ITU from other care areas.
Not being a health care professional nor a biologist, I look at data here:
https://www.worldometers.info/coronavirus/country/spain/
https://www.worldometers.info/coronavirus/country/germany
The only unbiased data are daily death totals, let us compare:
on 19-20 March, Germany reached approximately the level of Spain on 11-12 March.
This could mean that Spain is 7 days ahead of Germany.
Other factors could be "Non Pharmaceutical Intervention" as the term used by Health Policy expert says for "social distanciation/stay at home": Spain has acted strongly recently. Prominent people are either contaminated or quarantined, so now action has been taken.
I found these articles below interesting, because facts studied are 100 years old. Politicians and their Health Advisers might have been quicker had they read these or similar articles (published in 2007).
They refer to the incorrectly named Spanish influenza of 1918-1919 (it should have been named American influenza since the virus seems to have mutated to deadly in America, but a virus is a virus, no nationality, no border).
Large American cities (statistically relevant "samples") adopted very different approaches towards the epidemics, with very different efficiency levels. The most efficient show a reduction of 50% of the death peak over those acting too late.
The effect of public health measures on the 1918 influenza pandemic in U.S. cities
Martin C. J. Bootsma and Neil M. FergusonPNAS May 1, 2007
https://www.pnas.org/content/104/18/7588
Pandemic influenza: Studying the lessons of history
Stephen S. MorsePNAS May 1, 2007
https://www.pnas.org/content/104/18/7313
Rajkumar and Renaud, thank you very much for sharing your knowledge and opinions.
Rajkumar thinks that checklist proformas for those who are reallocated to ICU could improve critical care (in essence aviation safety).
Renaud, reading your recommendations: things have change so little in 102 years….
Best regards
Julio.
Maybe the Mediterranean model of family, in which grandparents are very involved in taking care of grandchildren has played an important role.
Julio.
The availability of healthcare in general and specifically critical care will affect case fatality. In China and Italy where large numbers of healthcare professionals were infected the capacity to deliver healthcare was substantially reduced.
Another important factor to consider when trying to interpret variation in mortality rates between countries is differences in cultural interpretation of quality of life. This impacts the social and medical ethics and the delivery, limitation and withdrawal of life sustaining therapies.
In many Western cultures quality of life is valued far more than quantity of life. In those setting limitation and even withdrawal of life sustaining therapies are a common mode of death.
In many Eastern cultures quantity of life is valued more than quality of life. In these settings treatment limitations and withdrawals of therapy are rare. Admission to intensive therapy units and prolonged organ support are common. Mode of death is often cardiac arrest.
These differences are magnified when there are limited resources particularly in Western countries. The social and medical acceptance of treatment limitations is increased; this may significantly increase case fatality rates.
@ Julio González Martín-Moro
and all interested
Like South Korea, Australia, Taiwan, USA and some other countries that have the means, capacity, and the health infrastructure to contain the COVID-19 pandemic by aggressive policy of "Test, Test, & Test" as recommended by WHO are overtesting and are able to manage the resultant positive cases (most of them asymptomatic or pre-symptomatic), are having a dilutional effect on mortality figures early on. Many population demographics (children, young, old, and very-old population segments as well as the prevalence of comorbidities affecting mortality rates) may also be important.
Lethality of the SARS-CoV-19 may also be dependent on the mutation rate and type of virus (L or R type) that is affecting a particular country.
Ultimately, the breaking point when the critically ill COVID-19 patients overwhelm the existing or upgraded ICUs with ventilators and the healthcare personals (or both) will decide whether the final mortality rates will be high, moderate or low.
This BREAKING POINT was reached early in ITALY, now showing up in SPAIN, and may be beginning to appear in USA (at least in New York). It may be seen later on in other countries. The countries where this breaking point is not reached before SARS-CoV-19 dies down, will ultimately have the lowest mortality figures.
If the pandemic continues at the same intensity for a long-time it may be catastrophic for the whole mankind.
Lets hope and pray that pandemic ends as it came in the near future.
Although outdated, this news report may enlighten you further:
https://www.almendron.com/tribuna/why-is-covid-19-death-rate-so-low-in-germany/
The coding of cause of death may be relevant.
For example, there has been a dramatic fall in the number of blood donors in Saudi Arabia a result of social isolation during the Covid-19 Pandemic. Supplies of blood are being depleted.
Patients may die as a result of not being transfused blood severe acute bleeding due to stress ulceration, for example. If the patient has severe or critical Covid-19, the cause of death is actually the Covid-19 but it is likely to be coded as GI tract bleeding.
Lies, damned lies and statistics as Disraeli said. It will be impossible to unpick the true effect of Covid-19 on patient outcomes.
in my opinion, everything results from the number of tests carried out and the way of entering the diagnosis of the cause of death. In well-developed countries, mortality is comparable.
Although early in the COVID-19 pandemic, Germany had enviable mortality rate of less than 2%, now it is 4%. This is still lower than a maximum of over 15% in UK and above 10% in many European countries.
This could be partly explained by dilutional effect of number of people tested compared to other European countries and better distancing measures, and possibly local homeopathic medication use.
Turkey and Russia are following the same policy of mass testing for COVID-19, with initial better mortality data.
I think it's useful to look at the best in class and worst in class:
"++++ best in class Portugal"
the neighbour of a country which has suffered so many deaths
They have contained the virus by acting early and resolutely
https://www.ft.com/content/67e1661b-f12b-4473-9bc2-aa2b5998ad73
A likely factor is that their health minister has a degree in health policy unlike several of her colleagues in other countries, who come from politics not from science:
https://en.wikipedia.org/wiki/Marta_Temido
"---- worst in class"
USA, no comment, just a fact: their president has lost a grandfather in the 1918 influenza pandemic...
Also sad that the USA has so many top scientists who have shown what worked 100 years ago and what did not, in this 1918 pandemic. See:
https://www.pnas.org/content/104/18/7582
https://www.pnas.org/content/104/18/7313
It's not an issue of not having tools, it's an issue of deciding to use them, and when, it seems...
"---- second worst in class, UK",
see explanations here:
REUTERS being a press agency is usually much more reliable than any media, here is what they said, which amounts to "10 000 more deaths than reported" on the day they published:
https://www.reuters.com/article/us-health-coronavirus-britain-casualties/uks-true-covid-19-death-toll-far-higher-than-daily-figure-data-suggests-idUSKBN22310D
From this analysis you can infer that the UK death total is already much higher than Italy's.
The analysis of the causes and factors explaining this has been made by the Financial Times:
https://www.ft.com/content/abdb7223-06da-4d52-b380-5606628b5f0e
It is difficult to believe that a country is safe, when the virus is already spreading massively in a neighbouring country within swimming distance...
See bottom-up model showing how the transmission plays out:
Preprint Covid19-transmission-model-Elderly Care Home-etc-2020-04-28
Reuters has published an interesting inquiry
https://www.reuters.com/investigates/special-report/health-coronavirus-britain-elderly/